Atrial Fibrillation Ive seen it all Eric N

Atrial Fibrillation: I’ve seen it all! Eric N Prystowsky, MD

Conflict of Interest • Consultant: Medtronic ; Cardio. Net • Institutional Fellowship support: Medtronic; St Jude

Early description of probable Atrial Fibrillation • “The pulse which is very abnormal and irregular shows that the cause of its irregularity migrates…one cannot use the irregularity of the pulse as a reliable prognostic sign” From: Moses Maimondes (1135 -1204)

Take Your Pulse

Treatment of Atrial Fibrillation - 1966 • Digitalis to slow ventricular rate • Quinidine or DC shock to restore sinus rhythm • Maintain SR: Quinidine indefinitely; Procainamide may be tried of quinidine ineffective or intolerable • Anticoagulation: - When established AF diagnosed and 1 -2 weeks later restore SR - Successful cardioversion to SR discontinue anticoagulants after several weeks - Persistent AF indefinite anticoagulation in RHD; not for other patients From: Charles K Friedberg, Diseases of the Heart 1966

Surgical Treatment of AF: The Maze Procedure From: Cox JL et al. , J Thorac Cardiovasc Surgery 1991; 101: 569 -583

Catheter Ablation of AV Junction From: Scheinman MM et al. , JAMA 1982; 248: 851 -55 (Gallagher JJ et al. NEJM 1982; 306: 194 -200)

Cardioversion of AF TEE Guidance: ACUTE Study Protocol AF > 2 days’ duration TEE-guided group n=619 Conventional therapy group n=603 Therapeutic A/C at time of TEE LA or LAA Thrombus detected No thrombus 4 weeks warfarin Repeat TEE 3 weeks warfarin Cardioversion 4 weeks warfarin Thrombus resolved Cardioversion Thrombus persists No cardioversion 4 weeks warfarin Follow-up examination Klein et al. N Engl J Med. 2001; 344: 1411 -1420.

Effect of Local Cooling on Aconitine-induced AF: Ectopic focus theory From: Scherf D, Romano FJ, Terranova R Am Heart J 1948; 46: 241 -251

CFAE: > 2 deflections CFAE: CL < 120 ms From: Nademanee K et al. , JACC 2004; 43: 2044

Single Procedure AF-free Survival in FIRM vs. Conventional Ablation (CONFIRM) From: Narayan SM et al. JACC 2014; 63: 1761 -8

Patient Q-35 HPI: 82 -year-old woman with a history of sudden right arm pain and numbness; no palpitations or dyspnea. PMH: Rheumatic fever as a child; CSBG at 75; hypertension; CHF; persistent AF for 2. 5 years PE: HR regular at 50/min; Lungs clear; 2/6 MR; no radial pulse in right arm ECHO: LVEF. 75; LA 3. 8; No LVH; 2+MR Meds: Warfarin (INR 2. 6); lanoxin 125 mcg QD; diltiazem CD 180 mg QD; furosemide 40 mg QD

Q-35

Algorithm for Selecting Antiarrhythmic Drug Therapy to Prevent Atrial Fibrillation From: Prystowsky EN Am J Cardiol 1996; 78: 35 -41

Maintenance of Sinus Rhythm No (or minimal) heart disease Hypertension Substantial LVH Flecainide Propafenone Sotalol No Amiodarone Dofetilide Catheter ablation Coronary artery disease Heart failure Dofetilide Sotalol Amiodarone Dofetilide Yes Amiodarone Flecainide Propafenone Sotalol Amiodarone Dofetilide Catheter ablation Amiodarone Catheter ablation From: ACC/AHA/ESC 2006 Atrial Fibrillation Management Guidelines

Strategies for Rhythm Control in Patients with Paroxysmal and Persistent AF From: 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation, Circulation, March 28, 2014

Rate Versus Rhythm Control in Patients with A. Fib (AFFIRM) From: AFFIRM investigators NEJM 2002; 347: 1825

“From Honolulu in the Pacific to Athens in the Aegean, the AFFIRM mismessage curtain has descended across Western medicine. ”

Patient Q-34 HPI: 18 year-old man referred for recent onset A. Fib. Two months ago, the patient was undergoing a tooth extraction under anesthesia and ECG monitoring, during which A. Fib occurred. He remains asymptomatic without medication. There is no family history of cardiac arrhythmias. PE: HR: 81, irregular; BP: 110/70 mm. Hg; Lungs: normal; Heart: normal ECHO: LVEF 58%; LA 3. 1 cm; no LVH Labs: Normal TFTs and electrolytes Holter: Mean 24 -hour HR 86; no hour > 100/min

The Electrophysiologist’s Dilemma We have done a lot, but we have not learned a lot about some key issues

Unresolved Questions in AF • What is the mechanism(s) of AF in humans? • Why at a particular moment in time does AF occur? • Can we develop an accurate method to identify AF patients at “real” risk for stroke? • When is PVI simply not enough, and then what to do next? • Can we identify patients with silent AF and prevent stroke?